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<meta name="description" content="读书笔记，感谢作者。①牙关紧闭（Trismus）通常在拔除第三磨牙时发生，是由于咀嚼肌痉挛导致的开口受限。这可能是由于翼状肌中头（medial pterygoid muscle）被注射器针头损伤导致的（行下牙槽神经阻滞麻醉时反复穿刺注射）。或者是手术区域痉挛，尤其是进行困难的长时间的手术的时候。其它因素是拔牙创感染，术后水肿等。处理：主要根据病因来决定处理方式。如果急性感染或血肿是牙关紧闭的原因，">
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<meta property="og:description" content="读书笔记，感谢作者。①牙关紧闭（Trismus）通常在拔除第三磨牙时发生，是由于咀嚼肌痉挛导致的开口受限。这可能是由于翼状肌中头（medial pterygoid muscle）被注射器针头损伤导致的（行下牙槽神经阻滞麻醉时反复穿刺注射）。或者是手术区域痉挛，尤其是进行困难的长时间的手术的时候。其它因素是拔牙创感染，术后水肿等。处理：主要根据病因来决定处理方式。如果急性感染或血肿是牙关紧闭的原因，">
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          <h1 class="post-title" itemprop="name headline">拔牙术后并发症</h1>
        

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        <p>读书笔记，感谢作者。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/01.jpg"><br>①牙关紧闭（Trismus）<br>通常在拔除第三磨牙时发生，是由于咀嚼肌痉挛导致的开口受限。这可能是由于翼状肌中头（medial pterygoid muscle）被注射器针头损伤导致的（行下牙槽神经阻滞麻醉时反复穿刺注射）。或者是手术区域痉挛，尤其是进行困难的长时间的手术的时候。其它因素是拔牙创感染，术后水肿等。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/02.jpg"><br>处理：主要根据病因来决定处理方式。如果急性感染或血肿是牙关紧闭的原因，建议热敷，使用广谱抗生素。其它措施：a.热理疗(heat therapy)，热袋(hot compresses)每小时热敷20分钟，直到症状消退。b.轻柔的按摩颞下颌关节区域。c.使用镇痛药物，抗感染药物和肌肉松解药物。d.每隔3-4小时理疗3-5分钟，包括开闭口训练，侧向运动，以期扩大开口范围<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/03.jpg"><br>e.使用镇静药物（溴基安定, bromazepam：1.5-3mg，每天两次），用来控制压力。<br>②血肿(hematoma)<br>是一个很常见的拔牙术后并发症，原因是毛细血管持续出血。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/04.jpg"><br>如果没有采用正确的方法止血（如结扎小血管等），就会出现血肿。血液在组织内集聚，而没法从已经关闭或严密缝合的创口中出来。根据操作，血肿可以在粘膜下，骨膜下，肌肉或筋膜内。对于有出血倾向的患者，在腭咽弓的地方形成血肿是相当危险的。<br>处理：如果术后数小时出现血肿，可以在头24小时用冰袋冷敷，然后用热疗使血肿更快消散。有的人建议使用抗生素和止痛药。<br>③瘀斑（Ecchymosis）<br>在某些病例中，术后患者的皮肤上会出现瘀斑，像毛细血管那样，使组织颜色变暗（decreased tissue tone）。不像那种面积广泛的损伤，它可能是在牵拉翻瓣的时候的损伤。要避免这个并发症，术中牵拉瓣必须轻柔，尤其是在神经孔，颧弓(貌似不对，zygomaticoalveolar crest，不知道怎么翻），以及尖牙区域。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/05.jpg"><br>处理：不需要特别处理。要告诉患者没有什么严重的情况，瘀斑会在数天内逐渐消散。<br>④水肿（edema）<br>是软组织创伤带来的继发损害，是软组织损伤导致淋巴管受损或阻塞引起的组织液外流，并在组织内集聚。术后48-72小时肿胀最大，然后就在术后3-4天开始消退。临床上，水肿的特征是光滑的，苍白的紧绷的皮肤。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/06.jpg"><br>当肿胀是由于炎症引起的时候，皮肤会发红，因为局部充血。依据组织创伤的程度，水肿的范围从小到中等，在很少的情况下，会很严重。有时，当手术在上颌时，水肿会延伸到下眼睑，因为该区域的组织非常的疏松。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/07.jpg"><br>或者患者有出血障碍（潜在紫癫），在这种情况下，皮肤会发紫。<br>处理：小范围的水肿不需要处理。为了预防，可以在术后立即使用冷敷。每半小时冷敷10-15分钟，持续4-6小时。如果水肿很严重，尤其是不消退的那种，必须小心处理。因为长时间的水肿有可能导致纤维化并发展成为纤维软骨联合。这种情况可以应用蛋白水解药物或溶纤维蛋白药物，如果是炎症引起的水肿，可以使用广谱抗生素。如果水肿是在咽旁间隙等区域(pharyngomaxillary)，有窒息的危险，可以使用250-500mg的氢化可的松。<br>⑤拔牙后肉芽肿(postextraction granuloma)<br>在拔牙后4-5天发生，由牙槽窝中的异物导致。例如，银汞充填体残留，骨残片（bone chips），小的牙碎片，牙石等。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/08.jpg"><br>异物激惹了该区域，因此拔牙创的愈合延迟，创面化脓。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/09.jpg"><br>处理：牙槽窝清创书，移除任何致病因素。<br>⑥牙槽窝疼痛<br>是一个常见的并发症，可以在麻药作用消失后立即发生，通常发生于下颌后牙，也可以发生于上颌后牙。由于颌骨致密，容易形成骨刺，尤其是拔牙比较困难，操作不当的病例。不平的骨边缘损伤了牙槽窝的软组织，导致疼痛和感染。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/10.jpg"><br>这种情况下，拔牙窝内充满了血凝块，帮助术后愈合。但是并不能发展成为覆盖创面的上皮。<br>处理：平整骨面，尤其是牙槽间隔。让患者服用止疼药，填塞纱布36-48小时。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/11.jpg"><br>（原来术后疼痛是这个原因！）<br>⑦纤维蛋白溶解性牙槽炎（Fibrinolytic Alveolitis，干槽症）<br>拔牙后2-3天发生，在这期间，血凝块破裂并移出牙槽窝，导致愈合延迟，牙槽骨表面坏死。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/12.jpg"><br>这被叫做纤维蛋白溶解性牙槽炎，它的症状是牙槽窝空虚，呼吸有恶臭，口腔内有异味，骨床裸露，放射到头部其它区域的剧烈疼痛。<br>处理：用温盐水柔和的冲洗牙槽窝，用含丁香酚的纱布填塞拔牙创，每24小时换药，直到疼痛缓解。也可以使用丁氧膏浸润的纱布，可以在牙槽骨内停留5天。也有报道显示用聚糖酐(dextranomer）颗粒或者膏状物很有效的。告知患者避免用患侧咀嚼，保持良好口腔卫生。<br>⑧创面感染<br>即可能发生在表浅的创面，也可能发生于深部的和广泛的组织。原因：a.使用被污染的器械和材料；b.有腐败组织覆盖在手术区域表面；c. 骨骼系统疾病（骨硬化症,osteopetrosis）导致的骨缺损，以及颌面部放疗术后区域。d.系统性疾病导致的感染易感性增加（如，白血病，粒细胞缺乏症。这些疾病导致免疫抑制。过去认为糖尿病也是其中之一，但是现在的观点认为控制良好的糖尿病不应当归入其中。<br>处理：如果牙医认为有术后感染的风险，预防性使用抗生素。如果感染已经发生，使用合适的抗生素。<br>⑨术后创面愈合被干扰<br>可以由局部或全身因素导致。全身因素包括血液疾病（粒细胞缺乏症，白血病），糖尿病，骨硬化症(osteopetrosis)，佩吉特症(Paget’s disease)，骨质疏松症（osteoporosis)。局部因素包括创面感染，增生性炎性肉芽肿，干槽症，放疗区域，良恶性肿瘤，由器械导致的创面损害（钻和挺）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/13.jpg"><br>缝线撕扯导致的瓣开裂。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0016-byshbfz/14.jpg"></p>
<p>拔牙并发症就完了。我平时就碰到过出血的，而且还没到出现瘀斑或者水肿的程度，应该是做的还比较少吧。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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